Provider Demographics
NPI:1659937407
Name:MIDDAUGH, KAITLYN MARIE (MD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:MIDDAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:YEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9425
Mailing Address - Fax:
Practice Address - Street 1:12955 SHELBYVILLE RD STE 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1538
Practice Address - Country:US
Practice Address - Phone:502-254-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY58927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program